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Journal of the Royal Society of Medicine Volume 83 May 1990
lengthens the T2- but shortens the T1-, and oxidative denaturation finally results in haemosiderin formation, producing parallel shortening of T1- and T2relaxation times. Thus to diagnose haemorrhage one requires a history, and access to T1- and T2-weighted images. Neither CT nor MR are sensitive in demonstrating intracranial aneurysms, but the authors' suggestion of > 1.5 cm is pessimistic: aneurysms exceeding 5 mm are demonstrated on contrast enhanced CT scans in most cases, using a section thickness of 5 mm or less. The detection of subarachnoid blood also necessitates 5 mm sections through the basal cistern/inferior sylvian fissure region, as partial volume averaging may prevent its visualization on 10 mm sections. A negative CT scan should be followed by lumbar puncture, since the timing of the scan may be suboptimal, and a small haemorrhage may not be detected. Assuming that the patient's neurological state permits, and that intracranial surgery would not be contraindicated for- any other reason, a confirmed subarachnoid haemorrhage should be followed by angiography as soon as practicable. T POWELL
Consultant Neuroradiologist, Royal Hallamshire Hospital, Sheffield
Hair loss with ulcerative colitis As a professional literature searcher, I am always amused whenever an au-thor writes that 'there are no reports in the literature' of any subject, because I can usually find some. Marley makes such a statement regarding hair loss associated with ulcerative colitis and with mesalazine (December 1989 JRSM, p 776). And, as might be supposed, yes there are. But, the irony of this particular incident is that two of them appear in a previous publication of the Royal Society of Medicine'2. DONALD A WINDSOR Information Scientist
Sir William Osler In Buchanan's article (January 1990 JRSM, p 45-47) he refers to Osler's gown having been given to Dr Michael C Brain by his late father Lord Brain. It was originally his PhD gown, given to my father, The late Sir Walter Morley Fletcher by Lady Osler when he took his honorary PhD at Oxford in 1926. After his death it went into store until 1951 when I found it and offered it to the Royal College of Physicians to convert to a Doctor of Medicine gown to be worn by any Oxford DM when giving a College lecture. Sir Russell Brain, then President ofthe Royal College of Physicians said he would prefer to have it for his son, then a medical student, to wear if he got an Oxford Doctor of Medicine. This and the rest of the story is given in detail by Walton J, Brain M, Fletcher C, Sir William Osler's Gown returns home (Br Med J 1984;289:1755-6). C M FLETCHER
Emeritus Professor of Clinical Epidemiology 24 West Square, London SEll 4SN
Seizure induction by alcohol The article by Heckmatt et al. (January 1990 JRSM, p6) dealing with seizure induction by alcohol in patients with epilepsy will be of interest to all forensic medical examiners (erstwhile police surgeons). We see a prodigious number of drunken epileptics in the cells - usually drunk and incapable rather than drunk and disorderly - but the number of these who actually have fits in the cells is, in my experience at least, relatively few. They are normally released from custody when they have sobered up, presumably, if the data in the article is correct, just in time to have their next seizure! N DAVIS
Immediate Past President Section of Clinical Forensic Medicine
Norwich, NY USA References 1 Tan R S-H, Samman PD. Ulcerative colitis, myasthenia gravis, atypical lichen planus, alopecia areata, vitiligo. Proc R Soc Med 1974;67:195-6 2 Thompson DM, Robinson TWE, Lennard-Jones J. Alopecia areata, vitiligo, scleroderma and ulcerative colitis. Proc R Soc Med 1974;67:1010-2
When is treatment for cancer economically justified? I hope that the article by Jennet and Buxton (January 1990 JRSM, p 25) will indeed start a discussion to which surely the surgeons and radiotherapists have most to contribute. Most colleagues would recognize that to precipitate the demise of a patient is cheaper and sometimes more convenient, at least to some relatives, than to prolong life. I hope that the authors would also accept that aetiological treatment is not by definition more expensive than hospice care but that the difference is not only between economical or useless therapy, but also between aetiological and symptomatic medicine. Modern medicine is about the former, recognizing the risks of the latter. V SVOBODA
Consultant in Radiotherapy & Oncology St Mary's Hospital, Portsmouth
Recognition and treatment of abdominal wall pain Gallegos and Hobsley (June 1989 JRSM, p 60) are correct in their assertion that nerve entrapment is not the only cause of 'benign' localized chronic abdominal pain. The use of local anaesthetic to confirm the diagnosis of 'trigger points' and nerve entrapment syndrome (also Hall and Lee, January 1990 JRSM, p 59) may protect the patient from an unnecessary laparotomy, but does not cure the pain. I hope that Hall and Lee and Gallegos and Hobsley will re-examine their patients in the light of my results in a series of 98 patients with painful conditions of the abdominal wall'. There were four groups ofpatients: accident and stress (which included anterior branches ofthe intercostal nerves), scar pain, linea alba strain, and 'maladie d'amour' (associated with conjugal activities). Injection of a mixture of triamcinolone acetonide and lignocaine into the site of pain cured the pain in 75-100% of the above groups. It is important to remove the pain if reassurance is to have optimum effect. I H J BOURNE MBE Brentwood Reference 1 Bourne IHJ. Treatment of painful conditions of the abdominal wall with local injections. Practitioner 1980;224:921-5
Journal of the Royal Society of Medicine Volume 83 May 1990
lengthens the T2- but shortens the T1-, and oxidative denaturation finally results in haemosiderin formation, producing parallel shortening of T1- and T2relaxation times. Thus to diagnose haemorrhage one requires a history, and access to T1- and T2-weighted images. Neither CT nor MR are sensitive in demonstrating intracranial aneurysms, but the authors' suggestion of > 1.5 cm is pessimistic: aneurysms exceeding 5 mm are demonstrated on contrast enhanced CT scans in most cases, using a section thickness of 5 mm or less. The detection of subarachnoid blood also necessitates 5 mm sections through the basal cistern/inferior sylvian fissure region, as partial volume averaging may prevent its visualization on 10 mm sections. A negative CT scan should be followed by lumbar puncture, since the timing of the scan may be suboptimal, and a small haemorrhage may not be detected. Assuming that the patient's neurological state permits, and that intracranial surgery would not be contraindicated for- any other reason, a confirmed subarachnoid haemorrhage should be followed by angiography as soon as practicable. T POWELL
Consultant Neuroradiologist, Royal Hallamshire Hospital, Sheffield
Hair loss with ulcerative colitis As a professional literature searcher, I am always amused whenever an au-thor writes that 'there are no reports in the literature' of any subject, because I can usually find some. Marley makes such a statement regarding hair loss associated with ulcerative colitis and with mesalazine (December 1989 JRSM, p 776). And, as might be supposed, yes there are. But, the irony of this particular incident is that two of them appear in a previous publication of the Royal Society of Medicine'2. DONALD A WINDSOR Information Scientist
Sir William Osler In Buchanan's article (January 1990 JRSM, p 45-47) he refers to Osler's gown having been given to Dr Michael C Brain by his late father Lord Brain. It was originally his PhD gown, given to my father, The late Sir Walter Morley Fletcher by Lady Osler when he took his honorary PhD at Oxford in 1926. After his death it went into store until 1951 when I found it and offered it to the Royal College of Physicians to convert to a Doctor of Medicine gown to be worn by any Oxford DM when giving a College lecture. Sir Russell Brain, then President ofthe Royal College of Physicians said he would prefer to have it for his son, then a medical student, to wear if he got an Oxford Doctor of Medicine. This and the rest of the story is given in detail by Walton J, Brain M, Fletcher C, Sir William Osler's Gown returns home (Br Med J 1984;289:1755-6). C M FLETCHER
Emeritus Professor of Clinical Epidemiology 24 West Square, London SEll 4SN
Seizure induction by alcohol The article by Heckmatt et al. (January 1990 JRSM, p6) dealing with seizure induction by alcohol in patients with epilepsy will be of interest to all forensic medical examiners (erstwhile police surgeons). We see a prodigious number of drunken epileptics in the cells - usually drunk and incapable rather than drunk and disorderly - but the number of these who actually have fits in the cells is, in my experience at least, relatively few. They are normally released from custody when they have sobered up, presumably, if the data in the article is correct, just in time to have their next seizure! N DAVIS
Immediate Past President Section of Clinical Forensic Medicine
Norwich, NY USA References 1 Tan R S-H, Samman PD. Ulcerative colitis, myasthenia gravis, atypical lichen planus, alopecia areata, vitiligo. Proc R Soc Med 1974;67:195-6 2 Thompson DM, Robinson TWE, Lennard-Jones J. Alopecia areata, vitiligo, scleroderma and ulcerative colitis. Proc R Soc Med 1974;67:1010-2
When is treatment for cancer economically justified? I hope that the article by Jennet and Buxton (January 1990 JRSM, p 25) will indeed start a discussion to which surely the surgeons and radiotherapists have most to contribute. Most colleagues would recognize that to precipitate the demise of a patient is cheaper and sometimes more convenient, at least to some relatives, than to prolong life. I hope that the authors would also accept that aetiological treatment is not by definition more expensive than hospice care but that the difference is not only between economical or useless therapy, but also between aetiological and symptomatic medicine. Modern medicine is about the former, recognizing the risks of the latter. V SVOBODA
Consultant in Radiotherapy & Oncology St Mary's Hospital, Portsmouth
Recognition and treatment of abdominal wall pain Gallegos and Hobsley (June 1989 JRSM, p 60) are correct in their assertion that nerve entrapment is not the only cause of 'benign' localized chronic abdominal pain. The use of local anaesthetic to confirm the diagnosis of 'trigger points' and nerve entrapment syndrome (also Hall and Lee, January 1990 JRSM, p 59) may protect the patient from an unnecessary laparotomy, but does not cure the pain. I hope that Hall and Lee and Gallegos and Hobsley will re-examine their patients in the light of my results in a series of 98 patients with painful conditions of the abdominal wall'. There were four groups ofpatients: accident and stress (which included anterior branches ofthe intercostal nerves), scar pain, linea alba strain, and 'maladie d'amour' (associated with conjugal activities). Injection of a mixture of triamcinolone acetonide and lignocaine into the site of pain cured the pain in 75-100% of the above groups. It is important to remove the pain if reassurance is to have optimum effect. I H J BOURNE MBE Brentwood Reference 1 Bourne IHJ. Treatment of painful conditions of the abdominal wall with local injections. Practitioner 1980;224:921-5
